Improvement in Documentation of Intake and Output Chart

Intake and Output (I/O) records in hospitals were often found to be incomplete and illegible. The form used to record I/O is not user-friendly — i.e., they feature miniscule boxes, ‘total’ lines that do not correspond with shift changes and lack of instructions. Complaints often received from Specialists & Doctors regarding calculation errors or no totalling of I/O. Moreover, Nursing Sisters objective rounds often saw incompleteness of I/O chart. This study aims to identify the types of mistakes in recording the existing I/O chart. The second aim is to find out whether shift totalling of I/O chart helps in reducing mistakes. We try to determine whether the identified mistakes were repeated in the new I/O Chart. This study was conducted from October till December 2010 in 9 selected wards in Sibu Hospital. Data collection was divided into 3 phases. A pre-implementation audit using a checklist was carried out. The compliance rate of completeness of documentation of I/O Chart was 63%. A one month trial of new I/O chart was being done in the selected 9 wards. Post implementation audit showed a significant improvement of compliance rate (88%). Feedback from health care workers (N=110) showed that, 89% of doctors (n=17) and 60% of nurses (n=93) in the sample prefer to use the new format as more practical and relevant to the changing shift of nurses and doctors’ ward round. It is suggested to implement the new format to increase compliance rate of documentation of I/O charting. Briefing should be given to nurses periodically and the new format should be introduced to nursing students in nursing colleges.

Long-term effect of repetitive transcranial magnetic stimulation on motor function recovery after acute ischemic stroke.

OBJECTIVE: Although there is evidence for short term benefits of rTMS in stroke, longer term effects have not been reported. The aim of the study was to evaluate the effect of two different frequencies of rTMS on motor recovery and on cortical excitability up to 1 year post-treatment. METHODS: Forty-eight patients with acute ischemic stroke were randomly classified into three groups. The first two groups received real rTMS over motor cortex (3 and 10 Hz respectively) of the affected hemisphere and the third group received sham stimulation of the same site, daily for five consecutive days. Disability was assessed before, after fifth sessions, and then after 1, 2, 3 and 12 months. Cortical excitability was assessed for both hemispheres before and after the second and fifth sessions. RESULTS: A significant 'rTMS x time' interaction was obtained indicating that real and sham rTMS had different effects on rating scales. This was because real rTMS produced greater improvement than sham that was evident even at one year follow-up. These improvements were associated with changes in cortical excitability over the period of treatment. CONCLUSION: These results confirm that real rTMS over motor cortex can enhance and maintain recovery and may be a useful add on therapy in treatment of acute stroke patients.

Selected Stro-1-enriched bone marrow stromal cells display a major suppressive effect on lymphocyte proliferation.

Mesenchymal stem cells (MSCs) have an immunosuppressive effect and can inhibit the proliferation of alloreactive T cells in vitro and in vivo. Cotransplantation of MSCs and hematopoietic stem cells (HSCs) from HLA-identical siblings has been shown to reduce the incidence of acute graft-vs.-host disease. MSCs are heterogeneous and data on the inhibitory effects of different MSC subsets are lacking. The antigen Stro1 is a marker for a pure primitive MSC subset. We investigated whether Stro-1-enriched induce a more significant suppressive effect on lymphocytes in a mixed lymphocyte reaction (MLR), and whether this action is related to a specific gene expression profile in Stro-1-enriched compared to other MSCs. We demonstrated that the Stro-1-enriched population elicits a significantly more profound dose-dependent inhibition of lymphocyte proliferation in a MLR than MSCs. One thousand expanded Stro-1-enriched induced an inhibitory effect comparable to that of 10 times as many MSCs. Inhibition by Stro-1-enriched was more significant in contact-dependent cultures than in noncontact-dependant cultures at higher ratio. The Stro-1-enriched inhibitory effect in both culture types was linked to increased gene expression for soluble inhibitory factors such as interleukin-8 (IL-8), leukemia inhibitory factor (LIF), indoleamine oxidase (IDO), human leukocyte antigen-G (HLA-G), and vascular cell adhesion molecule (VCAM1). However, tumor growth factor-beta1 (TGF-beta) and IL-10 were only up-regulated in contact-dependant cultures. These results may support using a purified Stro-1-enriched population to augment the suppressive effect in allogeneic transplantation.

Immunomodulatory effect of mesenchymal stromal cells: possible mechanisms.

Co-transplantation of mesenchymal stem cells (MSCs) and hematopoietic stem cells ameliorate hematopoietic reconstitution and induce tolerance. The immunomodulatory properties of MSCs have been demonstrated both in vivo and in vitro. MSCs can modulate function of immune cells such as T lymphocytes, antigen-presenting cells and natural killer cells. However, it is unknown whether MSCs given to patients that have undergone HSC transplantation could alleviate graft versus leukemia effect or could increase the risk of the infection. Proper characterization of MSC immunomodulatory mechanisms are crucial to anticipate the possible effect of MSC in the host. In the current report, interesting and contradictory results in the literature are reviewed in an attempt to understand the underlying mechanism. Differences in experimental designs and models used seem to be the underlying causes of discrepancy in reported results. Results of the few in vivo studies are controversial and further clinical studies are needed to confirm the efficiency and safety of MSCs in transplantation management.

The French Health Care System; What can We Learn?

All public systems look for the best organizational structure to funnel part of their national income into healthcare services. Appropriate policies may differ widely across country settings. Most healthcare systems fall under one of two broad categories, either Bismark or Beveridge systems. There is no simple ideal model for the organization of health services, but most healthcare systems that follow the Beveridge healthcare model are poor performers. The Libyan Health system is a low responsive, inefficient and underperforming system that lacks goals and/or SMART. (Specific, Measurable, Achievable, Realistic, Time specific) objectives. A look at different organization models in the world would reinforce efforts to reorganize and improve the performance of the Libyan National Healthcare services. The French Health Care System (FHCS) ranked first according to the WHO and the European Health Consumer Powerhouse. The FHCS was described to have a technically efficient, generous healthcare system that provides the best overall health care. This makes the FHCS a practical model of organization having many of the essential aspects of a modern national health service. In this review, we describe the main features of the FHCS, current challenges and future trends with particular attention paid to aspects that could be of importance to the Libyan Healthcare System.

Human bone marrow-derived mesenchymal stem cells.

Mesenchymal stem cells (MSCs) have elicited a great clinical interest, particularly in the areas of regenerative medicine and induction of tolerance in allogeneic transplantation. Previous reports demonstrated the feasibility of transplanting MSCs, which generates new prospects in cellular therapy. Recently, injection of MSCs induced remission of steroid-resistant acute graft-versus-host disease (GVHD). This review summarizes the knowledge and possible future clinical uses of MSCs.

The effect of nasal packing on arterial blood gases and acid-base balance and its clinical importance.

Arterial blood samples were taken from adult healthy patients before and 24 hours after bilateral nasal packing. The blood samples were investigated for PO2, PCO2, HCO3, pH and Hb. It was found that there is (i) an increase of high significance of PCO2 and HCO3-, (ii)) a significant increase of percentage of Hb., (iii) a highly significant decrease of PO2 in patients after nasal packing; (iv) as regards the pH, no significant difference was found. What we suggest is that bilateral anterior nasal pack results in hypoxia and hypercapnia due to hypoventilation.

Distal splenorenal shunts (Warren's operation) B-mode and real time ultrasonographic assessment.

B mode and real time ultrasonography have been used in a trial to demonstrate the patency of distal splenorenal shunt done in Warren's operation. Thirty seven patients with portal hypertension, and bleeding oesophageal varices were the subject of this study. Using B-mode ultrasonography in 70% of cases (26 patients), the splenic, left renal vein and the site of anastomosis were demonstrated. In 8% (3 patients), both splenic and left renal veins were seen patent, but the site of anastomosis was not detected. In the remaining 22% (8 patients), neither the left renal vein nor the site of anastomosis could be demonstrated. Using the Real-time two dimensional ultrasound, 9 of the 37 patients were examined. The patency of both veins and the site of the shunt was demonstrated in 90% (8 patients).